Self-reported interoceptive deficits in eating disorders: A meta-analysis of studies using the eating disorder inventory

Trajectories of negative affect prior to and following disordered eating behaviors among women with eating disorder pathology: An examination of the role of state-interoception

OBJECTIVE

Affect regulation theories of eating disorders (ED) posit that negative affect increases in the hours before and decreases following disordered eating behaviors (DEBs) in daily life, yet findings from studies assessing affective changes post-DEBs are mixed. This inconsistency may be due to the previously unassessed role of other transdiagnostic processes in these associations, such as interoception (the ability to sense and integrate information from bodily sensations). To address this research gap, the present study examined whether different interoception dimensions moderated negative affect trajectories surrounding DEBs in the natural environment.

METHOD

150 women with ED pathology (Mage = 21.0, SD = 4.1) completed 4 surveys targeting affect and DEBs each day for a 10-day ecological momentary assessment period. Polynomial multilevel models examined negative affect trajectories pre- and post-DEBs (dietary restriction, overeating, loss of control eating), and whether these trajectories varied based on daily interoception dimensions (not distracting, self-regulation, body listening and trust).

RESULTS

Negative affect increased prior to loss of control eating-but not dietary restriction or overeating-and decreased following all DEBs. Further, the magnitude of the decrease in negative affect that emerged post-dietary restriction decreased in strength as daily "not distracting" interoception increased. The other interoception dimensions did not moderate negative affect trajectories surrounding DEBs.

CONCLUSIONS

Allowing oneself to experience (vs. distract from) uncomfortable bodily sensations may weaken affect dysregulation processes that follow dietary restriction in daily life and are theorized to maintain DEBs. These results provide insight that may strengthen EDs theories, research, and inform interoception-focused interventions.

Illustrating the pathway from affect to somatic symptom: the Affective Picture Paradigm

High levels of somatic symptom distress represent a core component of both mental and physical illness. The exact aetiology and pathogenesis of this transdiagnostic phenomenon remain largely unknown. The Affective Picture Paradigm (APP) represents an innovative experimental paradigm to study somatic symptom distress. Based on the HiTOP framework and a population-based sampling approach, associations between facets of somatic symptom distress and symptoms induced by the APP were explored in two studies (N1 = 201; N2 = 254) using structural equation bi-factor models. Results showed that the APP effect was significantly positively correlated with general somatic symptom distress (PHQ-15, HiTOP), cardio-respiratory symptoms (PHQ-15), as well as difficulties identifying feelings. In conclusion, negative affective cues in the APP can elicit somatic symptoms, particularly in people with higher levels of somatic symptom distress. Difficulties identifying feelings might contribute to this phenomenon. Results are compatible with a predictive processing account of somatic symptom perception.

Sensory processing across eating disorders: A systematic review and meta-analysis of self-report inventories

OBJECTIVE

This review investigated the extant literature regarding the relationship between eating disorder diagnoses and sensory processing as measured by validated and reliable self-report inventories. Increasing evidence highlights the role of sensory processing in cognitive functions. Sensory processing is implicated in mental-ill health, including eating disorders (ED) and body image disturbances. However, the pathophysiological underpinnings of sensory processing, encompassing exteroception and interoception, in relation to ED remain underexplored.

METHOD

We included studies involving participants aged 15 years or older with an eating disorder diagnosis confirmed by semi-structured or structured interviews. We further limited inclusion to articles using validated and reliable self-report instruments to measure sensory processing. Our meta-analysis focused on studies using the interoceptive awareness subscale from the second version of the Eating Disorder Inventory. We used the Critical Appraisal checklist for quasi-experimental studies to assess the quality of included articles.

RESULTS

There were 19 studies that met our inclusion criteria. Most studies showed moderate-to-high quality. Anorexia nervosa (AN) and bulimia nervosa (BN) were associated with heightened exteroception. Moreover, people with AN reported a heightened sense of taste compared to those with BN. Our meta-analysis comprising 10 studies, 19 samples, and 6382 participants revealed that AN (binge-purge subtype) and BN were associated with increased interoceptive difficulties compared to AN (restrictive subtype) or binge-eating disorder.

DISCUSSION

Overall, this review emphasizes the need for a deeper investigation into sensory processing, spanning both exteroception and interoception, in relation to ED. This may prove important for individualizing person-centered care.

PUBLIC SIGNIFICANCE

How people process internal, for example, hunger, and external, for example, taste and sensations is known to influence cognition and mental-ill health, including ED and body image disturbances. However, the ways in which sensory processing may contribute to ED are incompletely understood. We found that individuals with AN or BN experienced heightened exteroception, while people with an eating disorder characterized by purging reported increased interoceptive difficulties. These patterns could inform the development of more personalized treatments.

Updating Prospective Self-Efficacy Beliefs About Cardiac Interoception in Anorexia Nervosa: An Experimental and Computational Study

Patients with anorexia nervosa (AN) typically hold altered beliefs about their body that they struggle to update, including global, prospective beliefs about their ability to know and regulate their body and particularly their interoceptive states. While clinical questionnaire studies have provided ample evidence on the role of such beliefs in the onset, maintenance, and treatment of AN, psychophysical studies have typically focused on perceptual and 'local' beliefs. Across two experiments, we examined how women at the acute AN (N = 86) and post-acute AN state (N = 87), compared to matched healthy controls (N = 180) formed and updated their self-efficacy beliefs retrospectively (Experiment 1) and prospectively (Experiment 2) about their heartbeat counting abilities in an adapted heartbeat counting task. As preregistered, while AN patients did not differ from controls in interoceptive accuracy per se, they hold and maintain 'pessimistic' interoceptive, metacognitive self-efficacy beliefs after performance. Modelling using a simplified computational Bayesian learning framework showed that neither local evidence from performance, nor retrospective beliefs following that performance (that themselves were suboptimally updated) seem to be sufficient to counter and update pessimistic, self-efficacy beliefs in AN. AN patients showed lower learning rates than controls, revealing a tendency to base their posterior beliefs more on prior beliefs rather than prediction errors in both retrospective and prospective belief updating. Further explorations showed that while these differences in both explicit beliefs, and the latent mechanisms of belief updating, were not explained by general cognitive flexibility differences, they were explained by negative mood comorbidity, even after the acute stage of illness.

The body interior in anorexia nervosa: from interoception to conceptual representation of body interior

Background

Body image disorders are well documented in anorexia nervosa (AN); however, knowledge of interoceptive awareness (IA) in this population remains poor. This descriptive study investigated whether and how the representation of the interior of the body may have an impact on IA.

Methods

The representations and knowledge of the body interior were evaluated with a drawing task in 34 women with AN and 34 healthy controls (HCs). A lexicometric analysis was performed on the vocabulary used to describe the drawn body parts in a structured interview. It was assumed that the conceptual representation of the body interior could be affected by or influence IA. Thus, the relationship between IA, measured with the heartbeat task and the ischemia-induction test, and the drawings was explored. Other scales, such as those of body shape, awareness or satisfaction, were used to assess affective representations of the body.

Results

The drawing, lexicometric and IA results were similar in the two groups. No correlations were found among IA, body representation scores and representation level of body interior. Only the representation of bones by the AN group was significantly different.

Discussion

Increased visual attention to the skeleton or greater awareness of bone health could explain the stronger representation of bones in the AN group. The psychophysical therapy received by some AN participants (73%) did not seem to have influenced IA. Our results do not support a relationship between IA and the representation of the body interior.Clinical trial registration:https://clinicaltrials.gov/, identifier NCT03988218.

Perceptual Dysfunction in Eating Disorders

Eating disorders (EDs) are characterized by abnormal responses to food and weight-related stimuli and are associated with significant distress, impairment, and poor outcomes. Because many of the cardinal symptoms of EDs involve disturbances in perception of one's body or abnormal affective or cognitive reactions to food intake and how that affects one's size, there has been longstanding interest in characterizing alterations in sensory perception among differing ED diagnostic groups. Within the current review, we aimed to critically assess the existing research on exteroceptive and interoceptive perception and how sensory perception may influence ED behavior. Overall, existing research is most consistent regarding alterations in taste, visual, tactile, and gastric-specific interoceptive processing in EDs, with emerging work indicating elevated respiratory and cardiovascular sensitivity. However, this work is far from conclusive, with most studies unable to speak to the precise etiology of observed perceptual differences in these domains and disentangle these effects from affective and cognitive processes observed within EDs. Further, existing knowledge regarding perceptual disturbances in EDs is limited by heterogeneity in methodology, lack of multimodal assessment protocols, and inconsistent attention to different ED diagnoses. We propose several new avenues for improving neurobiology-informed research on sensory processing to generate actionable knowledge that can inform the development of innovative interventions for these serious disorders.

Interoception, Affect, and Cognition in Older Adults

Interoception is the detection of signals that arise from within the body. Interoceptive sensitivity has been found to be associated with affect and cognition among younger adults, and examination of these relationships in older adult samples is beginning to emerge. Here, we take an exploratory approach to determine how demographic, affective, and cognitive variables relate to interoceptive sensitivity in neurologically normal older adults, aged 60-91 years old. Ninety-one participants completed a comprehensive neuropsychological battery, self-report questionnaires, and a heartbeat counting task to measure interoceptive sensitivity. Our findings revealed several relationships: 1) interoceptive sensitivity was inversely correlated with measures of positive emotionality: participants with higher interoceptive sensitivity tended to have lower levels of positive affect and trait extraversion; 2) interoceptive sensitivity was found to positively correlate with cognition: participants who performed better on the heartbeat-counting task also tended to perform better on a measure of delayed verbal memory; and 3) when examining the predictors of interoceptive sensitivity in a single hierarchical regression model, higher interoceptive sensitivity was related to: higher time estimation, lower positive affect, lower extraversion, and higher verbal memory. In total, the model accounted for 38% of the variability in interoceptive sensitivity (R2 = .38). These results suggest that, among older adults, interoceptive sensitivity is facilitative for aspects of cognition but perhaps disruptive for certain aspects of emotional experience.

Cardiac interoception in Anorexia Nervosa: A resting-state heartbeat-evoked potential study

OBJECTIVE

A deficit in interoception - the ability to perceive, interpret and integrate afferent signals about the physiological state of the body - has been shown in Anorexia Nervosa (AN), and linked to altered hunger sensations, body dysmorphia, and abnormal emotional awareness. The present high-density electroencephalography (hdEEG) study aims to assess cardiac interoception in AN and to investigate its neural correlates, using an objective neurophysiological measure.

METHOD

Heartbeat-evoked potentials (HEPs) were computed from 5 min of resting-state EEG and electrocardiogram (ECG) data and compared between individuals with AN (N = 22) and healthy controls (HC) (N = 19) with waveform, topographic, and source imaging analyses.

RESULTS

Differences in the cortical representation of heartbeats were present between AN and HC at a time window of 332-348 ms after the ECG R-peak. Source imaging analyses revealed a right-sided hypoactivation in AN of brain regions linked to interoceptive processing, such as the anterior cingulate and orbitofrontal areas.

CONCLUSIONS

To the best of our knowledge, this is the first study using hdEEG to localise the underlying sources of HEPs in AN. Results point to altered interoceptive processing during resting-state in AN. As our participants had a short duration of illness, this might not be the consequence of prolonged starvation. Interventions targeted at interoception could provide an additional tool to facilitate recovery.

Early childhood appetitive traits and eating disorder symptoms in adolescence: a 10-year longitudinal follow-up study in the Netherlands and the UK

BACKGROUND

Obesity and eating disorders commonly co-occur and might share common risk factors. Appetite avidity is an established neurobehavioural risk factor for obesity from early life, but the role of appetite in eating disorder susceptibility is unclear. We aimed to examine longitudinal associations between appetitive traits in early childhood and eating disorder symptoms in adolescence.

METHODS

In this longitudinal cohort study, we used data from Generation R (based in Rotterdam, the Netherlands) and Gemini (based in England and Wales). Appetitive traits at age 4-5 years were measured using the parent-reported Child Eating Behaviour Questionnaire. At age 12-14 years, adolescents self-reported on overeating eating disorder symptoms (binge eating symptoms, uncontrolled eating, and emotional eating) and restrictive eating disorder symptoms (compensatory behaviours and restrained eating). Missing data on covariates were imputed using Multivariate Imputation via Chained Equations. Ordinal and binary logistic regressions were performed in each cohort separately and adjusted for confounders. Pooled results were obtained by meta-analyses. Sensitivity analyses were performed on complete cases using inverse probability weighting.

FINDINGS

The final study sample included 2801 participants from Generation R and 869 participants from Gemini. Pooled findings after meta-analyses showed that higher food responsiveness in early childhood increased the odds of binge eating symptoms (odds ratio [OR]pooled 1·47, 95% CI 1·26-1·72), uncontrolled eating (1·33, 1·21-1·46), emotional eating (1·26, 1·13-1·41), restrained eating (1·16, 1·06-1·27), and compensatory behaviours (1·18, 1·08-1·30) in adolescence. Greater emotional overeating in early childhood increased the odds of compensatory behaviours (1·18, 1·06-1·33). By contrast, greater satiety responsiveness in early childhood decreased the odds of compensatory behaviours in adolescence (0·89, 0·81-0·99) and uncontrolled eating (0·86, 0·78-0·95) in adolescence. Slower eating in early childhood decreased the odds of compensatory behaviours (0·91, 0·84-0·99) and restrained eating (0·90, 0·83-0·98) in adolescence. No other associations were observed.

INTERPRETATION

In this study, higher food responsiveness in early childhood was associated with a higher likelihood of self-reported eating disorder symptoms in adolescence, whereas greater satiety sensitivity and slower eating were associated with a lower likelihood of some eating disorder symptoms. Appetitive traits in children might be early neurobehavioural risk factors for, or markers of, subsequent eating disorder symptoms.

FUNDING

MQ Mental Health Research, Rosetrees Trust, ZonMw.

Disturbed interoception in body dysmorphic disorder: A framework for future research

Body dysmorphic disorder is a severe psychiatric condition characterised by a preoccupation with a perceived appearance flaw or flaws that are typically not observable to others. Although significant advances in understanding the disorder have been made in the past decade, current explanations focus on cognitive, behavioural and visual perceptual disturbances that contribute to the disorder. Such a focus does not consider how perception of the internal body or interoception may be involved, despite (1) clinical observations of disturbed perception of the body in body dysmorphic disorder and (2) disturbed interoception being increasingly recognised as a transdiagnostic factor underlying a wide range of psychopathologies. In this paper, we use an existing model of hierarchical brain function and neural (predictive) processing to propose that body dysmorphic disorder involves defective interoception, with perceived appearance flaws being the result of 'interoceptive prediction errors' that cause body parts to be experienced as 'not just right'. We aim to provide a framework for interoceptive research into body dysmorphic disorder, and outline areas for future research.

Recognition of others' interoceptive states in those with and without eating disorders

BACKGROUND

The ability to recognize one's own emotions is associated with one's ability to recognize others' emotions. Beyond the domain of emotion, however, the relationship between recognition of one's own internal states (interoception) and others' interoceptive states has not been investigated, either in the typical population or clinical groups with interoceptive difficulties (e.g. eating disorders; EDs).

METHOD

This study investigated recognition of one's own and others' internal states in adults with and without eating disorders, using a high frequency visual noise paradigm. Participants completed self-report measures of interoception, alexithymia (difficulties recognising one's own emotional internal states) and ED symptomatology, and the Heartbeat Counting Task measure of cardiac interoceptive accuracy.

RESULTS

Alexithymia was significantly negatively correlated with recognition of others' interoceptive states. EDs were not associated with difficulties recognising others' interoceptive states.

CONCLUSIONS

The ability to recognise one's own emotional internal states is associated with the recognition of others' interoceptive states, which may contribute to social skills and the ability to care for others.

Development and Psychometric Validation of the Body Trust Scale

Interoception (e.g., abilities to recognize/attend to internal sensations) is robustly associated with psychopathology. One form of interoception, body trust, is relevant for the development of disordered eating and suicidal thoughts/behaviors. However, measures of body trust are narrow, despite research suggesting body trust is multifaceted. The aim of this study was to develop a comprehensive measure of body trust: The Body Trust Scale (BTS). 479 U.S. adults completed self-report surveys containing the BTS and psychopathology measures. Exploratory and confirmatory factor analyses revealed a three-factor structure: Comfort with One's Body, Physical Attractiveness, and Comfort with Internal Sensations. Factors showed strong construct, convergent, and divergent validity, as well as moderate predictive validity for suicidal thoughts/non-suicidal self-injury. Furthermore, factors showed strong internal consistency, test-retest reliability, and were invariant across the gender binary. The BTS can be used in research and clinical settings to understand how specific facets of body trust relate to psychopathology.

Elevated interoceptive deficits in individuals with eating disorders and self-injurious thoughts and behaviors: A replication and extension

INTRODUCTION

People with eating disorders (EDs) frequently report self-injurious thoughts and behaviors (SITBs). We aimed to replicate and extend findings demonstrating greater interoceptive deficits according to SITB severity. We predicted that interoceptive deficits would be greater among people with versus without lifetime SITBs and among those with multiple suicide attempts compared with single attempts or nonsuicidal self-injury. We also predicted that interoception would be increasingly impaired with greater current suicidality severity.

METHOD

Adults (N = 118) seeking ED treatment reported current and lifetime SITBs upon admission to treatment. We used planned contrasts to compare interoceptive deficits (self-reported using the Eating Disorders Inventory) by SITB and current suicidality groups (assessed by self-report and clinical interview).

RESULTS

Interoceptive deficits were greater among people with any SITB history compared to those without. People with multiple suicide attempts did not differ in interoceptive deficits from those with single attempts or only nonsuicidal self-injury. Interoceptive deficits were elevated among those with any current suicidality compared to those with no suicidal symptoms; interoceptive deficits did not differ according to severity of suicidality.

CONCLUSION

Among those with EDs, interoceptive deficits are elevated among those with concurrent SITBs. Interventions aimed at improving interoception may reduce the risk for SITBs.

Intrinsic timescales and predictive allostatic interoception in brain health and disease

The cognitive neuroscience of brain diseases faces challenges in understanding the complex relationship between brain structure and function, the heterogeneity of brain phenotypes, and the lack of dimensional and transnosological explanations. This perspective offers a framework combining the predictive coding theory of allostatic interoceptive overload (PAIO) and the intrinsic neural timescales (INT) theory to provide a more dynamic understanding of brain health in psychiatry and neurology. PAIO integrates allostasis and interoception to assess the interaction between internal patterns and environmental stressors, while INT shows that different brain regions operate on different intrinsic timescales. The allostatic overload can be understood as a failure of INT, which involves a breakdown of proper temporal integration and segregation. This can lead to dimensional disbalances between exteroceptive/interoceptive inputs across brain and whole-body levels (cardiometabolic, cardiovascular, inflammatory, immune). This approach offers new insights, presenting novel perspectives on brain spatiotemporal hierarchies and interactions. By integrating these theories, the paper opens innovative paths for studying brain health dynamics, which can inform future research in brain health and disease.

Sensing the Snacking Experience: Bodily Sensations Linked to the Consumption of Healthy and Unhealthy Snack Foods-A Comparison between Body Mass Index Levels

The World Health Organisation (WHO) has highlighted the need for immediate action regarding the escalating global prevalence of overweight and obesity. Based on the need for long-term strategies supporting dietary behaviour changes, the concept of 'interoception' (i.e., sensing the body's internal state) has been proposed as promising for understanding and controlling food intake behaviours. As eating behaviours are motivated by the need for securing energy demands as well as the desire for pleasure, investigating the bodily sensations perceived in relation to food consumption can support our understanding of human food and eating behaviours. Here, a consumer study was conducted on 286 Danish consumers to explore the interoceptive experience of snack food consumption. This study included an investigation of the consumers' interoceptive capabilities and ability to feel pleasure, intuitive eating behaviours, snack food consumption frequency, the drivers of snack food consumption, food-related pleasure, and post-ingestive sensations linked to snack food consumption. The study was conducted on consumers with different Body Mass Index (BMI) levels to study potential differences between these groups. The study showed normal interoceptive capabilities and abilities to feel pleasure, with no differences between BMI groups. Regarding intuitive eating, the study found intuitive eating to be more prevalent among the group holding normal BMI. No significant differences between BMI groups were found in terms of snack intake frequency. However, differences between BMI groups were found in terms of: the drivers of snack consumption, the aspects bringing food-related pleasure from snack consumption, and the post-ingestive sensations felt after eating snack foods.

The role of developmental caregiving programming in modulating our affiliation tendency and the vulnerability to social anxiety and eating disorders

Attachment is the evolutionarily-established process through which humans create bonds with others to receive care from them. The phenomenon is as essential to our physical survival as it is to our psychological development. An increasing number of studies demonstrates that in sensitive periods during the early years of life, our brain circuitry is programmed in the interactions with our caregivers, with the imprinting of information over multiple attachment dimensions. Adopting a basic brain-computer analogy, we can think of this knowledge as the psycho-social firmware of our mind. According to a recently proposed extension of the classical three-dimensional view, one attachment dimension - somaticity - concerns the caregiver's task of reflecting and confirming the child's (internal) states - such as sensations, emotions, and representations - to support the child's ability to identify and define those entities autonomously. Relying on multidisciplinary evidence - from neuroscientific, developmental, evolutionary, and clinical sources - we suggest that somaticity (H1) has the adaptive function to modulate our tendency to comply and affiliate with a reference group but also (H2) increases the vulnerability to developing Social Anxiety (SA) and Eating Disorders (EDs). We evaluate H1-H2, (1) indicating the evolutionary role of somaticity in modulating our affiliation tendency to optimize the ancestral threat-opportunity balance coming from infectious diseases and (2) showing the deep connection between SA-EDs and the features most closely related to somaticity - interoception and parenting style. Finally, we discuss three relevant implications of H1-H2: (A) Bringing into research focus the adaptive role of our firmware knowledge system versus the hardware (neural substrate) and software (higher cognition) ones. (B) Complementing the well-grounded Objectification and Allocentric Lock Theories, allowing us to integrate multiple levels of explanation on the etiology of psychopathology. (C) Suggesting the design of new psychological treatments. While not aiming to prove H1-H2, our analysis supports them and encourages their direct testing.

Clarifying the pathway from anxiety sensitivity to binge eating: The mediating role of depressive symptoms in a 3-week, 3-wave longitudinal study of undergraduates

Anxiety sensitivity (AS) - characterized by a persistent fear that arousal-related bodily sensations will lead to serious cognitive, physical, and/or social consequences - is associated with various psychopathologies, including depressive symptoms and binge eating. This 3-week, 3-wave longitudinal study examined the relation between AS (including its global AS factor and lower-order AS cognitive, physical, and social concern dimensions), depressive symptoms, and binge eating among 410 undergraduates from two universities. Using generalized estimating equation models, we found that global AS, AS social concerns, and depressive symptoms predicted binge eating during any given week. Mediation analyses showed that global AS (as a latent variable with its lower-order AS dimensions as indicators), AS cognitive concerns, and AS physical concerns at Wave 1 predicted subsequent increases in depressive symptoms at Wave 2, which, in turn, led to increases in binge eating at Wave 3. Findings contribute to a better understanding of the interplay between AS, depressive symptoms, and binge eating, highlighting the role of binge eating as a potential coping mechanism for individuals with high AS, particularly in managing depressive symptoms. This study underscores the importance of AS-targeted intervention and prevention efforts in addressing depressive symptoms and binge eating.

Pain experience in eating disorders: The mediating role of depression, alexithymia and interoceptive awareness

OBJECTIVE

Evidence suggests reduced sensitivity to pain due to high pain threshold in anorexia and bulimia nervosa and a possible role of depression, alexithymia and interoceptive awareness on pain experience. This study examined whether self-report and real-time evoked pain experience were mediated by depression, alexithymia and interoceptive awareness in a comprehensive sample of patients with eating disorders (ED).

METHOD

145 participants (90 ED, 55 healthy controls (HC)) underwent a real-time evoked examination of pain and completed self-report questionnaires for pain (Pain Detect Questionnaire (PD-Q), PD-Q VAS, Leeds Assessment of Neuropathic Symptoms and Signs), depression (BDI-II), interoceptive awareness Multidimensional Assessment of Interoceptive Awareness (MAIA), and alexithymia (TAS-20). Three mediation models, with ED diagnosis as independent variable, and BDI, MAIA and TAS-20 as mediators, were tested.

RESULTS

Participants with ED and HC exhibited similar pain type and intensity (self-report and real-time). Eating disorders diagnosis was associated with lower self-report pain intensity and non-neuropathic like pain experience (model 1-2). Depressive symptoms partially (model 1-2) or fully (model 3) mediated the association between ED diagnosis and pain experience, alone (model 1) or via alexithymia (model 3). Interoceptive awareness did not influence pain symptomatology.

DISCUSSION

ED diagnosis is associated with non-neuropathic and lower pain experience. However, concurrent depression and alexithymia are associated with higher pain symptoms and neuropathic features. These results could inform clinicians about the influence of psychopathology on pain experience in ED.

Beyond Gender: Interoceptive Sensibility as a Key Predictor of Body Image Disturbances

Body image disturbance (BID) involves negative attitudes towards shape and weight and is associated with lower levels of interoceptive sensibility (IS) (the subjective perceptions of internal bodily states). This association is considered a risk factor for developing eating disorders (EDs) and is linked to altered sensorimotor representations of the body (i.e., body schema). BIDs manifest across genders and are currently understudied in men. This study investigated gender-related differences in BID and its relationship to the body schema and IS. Data were collected from 86 men and 86 women. BID was assessed using questionnaires measuring self-objectification, state, and trait body dissatisfaction. IS was measured via the MAIA-2. The body schema was indexed via an embodied mental rotation task. Results showed that women reported higher BID than men across all scales. Gender differences in sub-components of interoceptive sensibility were found. Overall, both gender and interoceptive sensibility predicted BID. However, interoceptive sensibility exhibited its own unique association with BID beyond the influence of gender. BID, IS and gender were not significant predictors of performance in the body schema task. Therefore, while gender predicts differences in BID and interoceptive sensibility, there was no evidence of gender-related differences in body schema.

Interoceptive Awareness Among the General Public in Saudi Arabia: A Cross-Sectional Study

Background Interoception refers to the cognitive process of perceiving internal bodily states. This encompasses various physiological indicators, including heart rate fluctuations, stomach distention, internal temperature, hydration levels, sensory input from free nerve terminals in the fascia and muscles, as well as hormonal, stretch, and pain receptors. This study aimed to examine the interoceptive awareness among the general public in Saudi Arabia. Methods A cross-sectional online survey was undertaken in Saudi Arabia to investigate the level of interoceptive awareness within the overall population of the country in October 2023. This research used a previously developed questionnaire named the Multidimensional Assessment of Interoceptive Awareness, version 2 (MAIA-2). In a binary logistic regression analysis, the mean interoceptive awareness score of the participants was utilized as the dummy variable to determine the variables that influence interoceptive awareness. Results A total of 814 participants were involved in this study. Overall, the study participants demonstrated a marginal level of interoceptive awareness with a mean score of 94.3 (standard deviation (SD): 29.3) out of 185 (representing 51.0% of the maximum attainable score). The mean interoceptive score was not consistent across different subscales and ranged between 37.7% and 63.3%. The highest mean interoceptive score was observed for the Trusting subscale (9.5 (SD: 4.5) out of 15) (representing 63.3% of the maximum attainable score for this subscale). The lowest mean interoceptive score was observed for the Not-Distracting subscale (11.3 (SD: 6.9) out of 30) (representing 37.7% of the maximum attainable score for this subscale). Binary logistic regression analysis did not identify any statistically significant difference in the likelihood of having a higher level of interoceptive awareness among the participants based on their demographic characteristics (p>0.05). Conclusion The participants in our research demonstrated a modest degree of interoceptive awareness. The study's results suggest that the participants demonstrated a heightened inclination towards internal experiences rather than being attentive to their bodily sensations. Further investigation is required to examine interoceptive awareness across various cohorts.

The role of interoception in age-related obesity: A structural equation modelling study

The obesity pandemic and its adverse effect on health and quality of life are well established. In younger populations, interoception and aberrant eating behaviour contribute to overconsumption and being overweight. Although the incidence of obesity is higher in older individuals, they remain under-researched in the obesity literature. Therefore, the present study considered the role of general (interoceptive sensibility) and appetite-specific (hunger drive and satiety responsiveness) interoception and obesogenic eating behaviour (food responsivity, emotional eating, enjoyment of eating) in the association between age and BMI. A total of 1006 female adults (aged 18 to 80) completed the Adult Eating Behaviour Questionnaire and the Interoceptive Attention and Accuracy scales. Structural Equation Modelling (SEM) in AMOS was used to explore the data for multiple serial mediation effects. Despite being more overweight, older adults reported lower interoceptive attention, hunger drive, emotional overeating, food responsivity, and enjoyment of food. In contrast, compared to younger adults, older adults reported a higher interoceptive accuracy, and a similar responsivity to satiety. Importantly, two indirect pathways positively mediated the link between age and BMI: (1) age ➤(-)➤ interoceptive attention ➤(+)➤ satiety responsivity ➤(-)➤ emotional eating ➤(+)➤ BMI and (2) age ➤(-)➤ interoceptive attention ➤(+)➤ satiety responsivity ➤(-)➤ food responsivity ➤(+)➤ BMI. However, a stronger antagonistic indirect pathway was also present: age ➤(-)➤ interoceptive attention ➤(+)➤ hunger drive ➤(+)➤ emotional eating ➤(+)➤ BMI. The present findings suggested that overall reduced interoceptive attention in older adults may protect against weight gain by lowering hunger and the propensity towards obesogenic eating behaviours. These findings have implications for the design of appetite interventions in older populations.

Body image disturbance, interoceptive sensibility and the body schema across female adulthood: a pre-registered study

Introduction

Body image disturbance (BID) typically involves explicit negative attitudes toward one's shape and weight and is associated with altered interoceptive sensibility (the subjective perception of internal bodily states). This association is a known risk factor for the development and maintenance of eating disorders. However, while research has centred on younger women with eating disorders, diverse facets of BID appear in women without eating disorders across adulthood. Research shows that in the general population, young women (ages 18-25) with high BID exhibit disturbances in the body schema: an implicit sensorimotor representation of the body in space which includes mental simulation of a movement such as motor imagery. Given that body image is subject to age-related influences, it is important to investigate how age-related variation in BID can influence the body schema beyond young adulthood alone. Here, we examine the relationship between BID, interoceptive sensibility and the body schema across female adulthood.

Methods

Cross-sectional data was collected online from 1,214 women across four age groups: Young adults (18-24), Adults (25-39), Middle-aged adults (40-59), and Older aged adults (60-75). BID was indexed by questionnaires measuring body objectification, state, and trait body dissatisfaction. Interoceptive sensibility (IS) was measured using the MAIA-2 questionnaire. The body schema was evaluated through the Own Body Transformation task: a mental rotation task which assesses the capacity to make an embodied mental transformation.

Results

Analyses revealed that while body objectification and trait body dissatisfaction decreased from young to older adulthood, state body dissatisfaction showed a marked increase. A negative relationship between IS and BID across all age groups was also evidenced. Finally, age, BID and orientation of the presented body were significant predictors of the time taken to make an embodied transformation.

Discussion

These findings highlight the consistent relationship of BID and IS across age groups beyond young adulthood and demonstrate the varying importance of different aspects of BID as individuals age. We also evidence for the first time that disruptions in body image have the potential to impact implicit sensorimotor representations of the body even in women without eating disorders across female adulthood.

Food stimuli decrease activation in regions of the prefrontal cortex related to executive function: an fNIRS study

PURPOSE

Overweight/obese individuals show impairments in executive functions such as inhibitory control. However, the neural mechanisms underlying these disturbances-and specifically, whether or not they involve altered activation of the specific prefrontal cortex regions-are not yet fully understood.

METHODS

The motivational dimensional model of affect suggests that high approach-motivated positive affect (e.g., desire) may impair executive function. In the present study, we investigated individual differences in neural responses to videos of food stimuli, and examined brain activity during a cognitive task in an approach-motivated positive state using functional near-infrared spectroscopy (fNIRS). In Experiment 1, in 16 healthy young adults, we tested whether prefrontal cortex activation differed during a food video clip versus a neutral video clip. Then, after viewing each video clip, we tested for differences in executive function performance and prefrontal cortex activation during a Stroop task. Experiment 2 was the same, except that we compared 20 overweight/obese with 20 healthy young adults, and it incorporated only the food video clip.

RESULTS AND CONCLUSIONS

The results of both experiments indicated that food stimuli decrease activation in regions of the prefrontal cortex related to executive function. This study also suggests that overweight/obese might consciously suppress their responses to a desired stimulus, yet here it seems that effect was less pronounced than in healthy controls.

LEVEL OF EVIDENCE

Level II, Cohort Studies.

Interoceptive awareness and emotional eating in college women: the role of appetite and emotional awareness

Objective: Emotional eating is prevalent among college women. Deficits in interoceptive awareness, or the ability to perceive and identify internal sensations, are associated with emotional eating. Separately examining the specific components of interoceptive awareness, appetite and emotional awareness, in relation to emotional eating may improve prevention and treatment of emotional eating in college women.Participants: 143 women at an urban Northeastern university.Methods: This was a cross-sectional study using self-report measures of interoceptive awareness, appetite and emotional awareness, emotional eating, and depression. Simultaneous regression analyses examined the independent association of appetite and emotional awareness with emotional eating, controlling for depression.Results: Consistent with hypotheses, lower interoceptive awareness was associated with higher emotional eating. Appetite and emotional awareness, were each uniquely associated with emotional eating independent of depression, even when entered simultaneously.Conclusions: Future prevention and treatment of emotional eating in college women should target improvements in appetite and emotional awareness.

Linguistic embodiment in typical and atypical anorexia nervosa: Evidence from an image-word matching task

OBJECTIVE

The integration of sensory, motor, and cognitive systems is embodied cognition, according to which mind and body are not separate and distinct, and our body (and our brain, as part of the body) contributes to determining our mental and cognitive processes. In spite of limited data available, Anorexia nervosa (AN) appears as a condition in which embodied cognition is altered, in particular, if we consider bodily sensations and visuospatial information processing. We aimed to evaluate the ability to correctly identify body parts and actions in both full (AN) and atypical AN (AAN), looking at the role of the underweight status.

METHOD

A group of 143 females (AN = 45, AAN = 43, unaffected women = 55) was enrolled. All participants performed a linguistic embodied task to evaluate the association between a picture-showing a bodily action-and a written verb. Additionally, a subsample of 24 AN participants performed a retest after stable weight recovery.

RESULTS

Both AN and AAN demonstrated an abnormal ability to evaluate the picture-written verb associations, especially if the involved bodily effectors were the same in both stimuli (i.e., pictorial and verbal) and needed a longer response time.

CONCLUSIONS

Specific embodied cognition linked to body schema seems to be impaired in persons with AN. The longitudinal analysis showed a difference between AN and AAN only in the underweight condition, suggesting the presence of an abnormal linguistic embodiment. More attention should be devoted to embodiment during AN treatment to improve bodily cognition, which might, in turn, diminish body misperception.

Testing visual self-misperception in anorexia nervosa using a symmetrical body size estimation paradigm

OBJECTIVE

Individuals diagnosed with anorexia nervosa (AN) often report seeing themselves as overweight. While body size estimation tasks suggest that such individuals overestimate their body size, these tasks have failed to establish whether this misestimation stems from visual misperception. Misestimation might, instead, be due to response bias. We designed a paradigm to distinguish between visual and response bias contributions to body size misestimation: the symmetrical body size estimation (s-BSE) paradigm.

METHOD

The s-BSE paradigm involves two tasks. In the conventional task, participants estimate the width of their photographed body by adjusting the size of a rectangle to match. In the transposed task, participants adjust the size of a photograph of their body to match the rectangle. If overestimation stems exclusively from visual misperception, then errors in each task would be equal and opposite. Using this paradigm, we compared the performance of women diagnosed with AN (n = 14) against women without any eating disorder (n = 40).

RESULTS

In the conventional task, we replicated previous findings indicating that both women with AN and women without any eating disorder overestimate their body size. In the transposed task, neither group adjusted the bodies to be narrower than the rectangle. Participants with AN set their photographs to be significantly wider.

DISCUSSION

While we replicated previous findings of body size overestimation amongst women with AN and those without any eating disorder, our results are inconsistent with the hypothesis that such overestimation stems exclusively from visual misperception and instead suggest a substantial response bias effect.

PUBLIC SIGNIFICANCE

Women with anorexia nervosa overestimate their own body size. Research has not yet determined whether this overestimation stems from them seeing themselves as larger or other, non-visual factors. We employ a new method for distinguishing these possibilities and find that non-visual factors influence size estimates for women with and without anorexia nervosa. This method can help future research control for non-perceptual influences on participant responses.

The impact of floatation therapy on body image and anxiety in anorexia nervosa: a randomised clinical efficacy trial

Background

Body image disturbance and anxiety are core features of anorexia nervosa (AN), a psychiatric disorder with one of the highest mortality rates. This study examined the efficacy of a novel non-pharmacological treatment, floatation-REST (Reduced Environmental Stimulation Therapy) on body image disturbance and anxiety in inpatients with AN.

Methods

This parallel group randomised controlled trial compared floatation-REST vs. care as usual in women and girls hospitalised for treatment of AN in Tulsa, Oklahoma, USA. Participants were randomised on a 2:1 ratio to receive eight, twice-weekly, 60-min floatation-REST sessions for 4 weeks, in addition to care as usual, or to receive care as usual. The primary outcome was the average change in body dissatisfaction from pre- to post-float as measured by the Photographic Figure Rating Scale. The secondary outcome was the average change in anxiety from pre- to post-float as measured by the state version of the State Trait Anxiety Inventory. Longitudinal effects of floatation-REST on body dissatisfaction were also examined. All analyses were conducted using the intention-to-treat principle. Planned linear mixed models tested the effect of floatation-REST vs. care as usual. The trial was preregistered (clinicaltrials.govNCT03610451).

Findings

Between March 16, 2018 and February 25, 2021, 133 participants were screened for eligibility, and 86 were consented. Eighteen were excluded after consent, for a final randomisation sample of 68 participants (45 floatation-REST; 23 care as usual). There were two session by condition interactions on body dissatisfaction (p = 0.00026) and state anxiety (p < 0.0001), such that the floatation-REST group exhibited acute (i.e., pre- to post-session) reductions in body dissatisfaction (floatation-REST group mean change (Δm) = -0.43; 95% CI -0.56 to -0.30, p < 0.0001, Cohen's d = 0.23), and acute reductions in anxiety (floatation-REST group Δm = -15.75; 95% CI -17.95 to -13.56, p < 0.0001, Cohen's d = 1.52); however, the care as usual group exhibited no significant changes. With regard to longitudinal results, there was a significant time by treatment interaction between baseline and immediately post intervention (p = 0.012) and baseline and six-month follow up (p = 0.0019). At immediately post intervention, there was a trending reduction in body dissatisfaction for the floatation-REST group (Δm = -0.41, 95% CI -0.86 to 0.03, p = 0.068) and care as usual group (Δm = 0.61; 95% CI -0.04 to 1.27, p = 0.070). At six-months post-intervention, the floatation-REST group exhibited lower body dissatisfaction (Δm = -0.91; 95% CI -1.37 to -0.45, p = 0.0020, Cohen's d = 0.53) whereas the care as usual group reported no change in body dissatisfaction (Δm = 0.35; 95% CI -0.28 to 0.98, p = 0.96) relative to baseline. There were no adverse events related to the trial during the study.

Interpretation

Our findings suggest that Floatation-REST decreased body dissatisfaction compared to care as usual acutely after each float session and at six-month follow-up. Floatation-REST has potential utility for the treatment of body image disturbance and anxiety in AN. These results may be limited by some generalisability concerns given the recruitment of a modest sample receiving inpatient treatment at a single site.

Funding

The William K. Warren Foundation.

Dysfunctional decision-making in binge-eating disorder: A meta-analysis and systematic review

Binge-Eating Disorder (BED) involves anticipatory craving and urges, subjective loss-of-control during binge-eating episodes, and post-feeding psychological distress and guilt. Evidence indicates neurocognitive dysfunctions contribute to BED onset, maintenance, and treatment response. However, an integrated understanding of how cognitive processes underpin BED symptomology is lacking. We utilised a multi-stage decision-making model defining ten cognitive processes underpinning Preference Formation, Choice Implementation, Feedback Processing, and Flexibility/Shifting, to comprehensively review research published since 2013. We used preregistered PICOS criteria to assess 1966 articles identified from PubMed, PsycInfo, and Scopus database searches. This yielded 50 studies reporting behavioural cognitive tasks outcomes, comparing individuals with BED to controls with normal and higher weight. Meta-analyses revealed a unique profile of cognitive dysfunctions that spanned all decision-making stages. Significant deficits were evident in Uncertainty Evaluation, Attentional Inhibition, Choice Consistency, and Cognitive Flexibility/Set-shifting. We propose a novel model of dysfunctional decision-making processes in BED and describe their role in binge-eating behaviour. We further highlight the potential for cognitive interventions to target these processes and address the significant treatment gap in BED.

The influence of stress on the neural underpinnings of disinhibited eating: a systematic review and future directions for research

Disinhibited eating involves overconsumption and loss of control over food intake, and underpins many health conditions, including obesity and binge-eating related disorders. Stress has been implicated in the development and maintenance of disinhibited eating behaviours, but the mechanisms underlying this relationship are unclear. In this systematic review, we examined how the impact of stress on the neurobiological substrates of food-related reward sensitivity, interoception and cognitive control explains its role in disinhibited eating behaviours. We synthesised the findings of functional magnetic resonance imaging studies including acute and/or chronic stress exposures in participants with disinhibited eating. A systematic search of existing literature conducted in alignment with the PRISMA guidelines identified seven studies investigating neural impacts of stress in people with disinhibited eating. Five studies used food-cue reactivity tasks, one study used a social evaluation task, and one used an instrumental learning task to probe reward, interoception and control circuitry. Acute stress was associated with deactivation of regions in the prefrontal cortex implicated in cognitive control and the hippocampus. However, there were mixed findings regarding differences in reward-related circuitry. In the study using a social task, acute stress associated with deactivation of prefrontal cognitive control regions in response to negative social evaluation. In contrast, chronic stress was associated with both deactivation of reward and prefrontal regions when viewing palatable food-cues. Given the small number of identified publications and notable heterogeneity in study designs, we propose several recommendations to strengthen future research in this emerging field.

Interoceptive awareness in a Norwegian population: psychometric properties of the Multidimensional Assessment of Interoceptive Awareness (MAIA) 2

BACKGROUND

Interoception plays a vital role in human cognition and emotion and is an increasingly important part of clinical studies of mind-body approaches and mental health. Interoceptive awareness (IA) encompasses numerous mind-body components and can be assessed by employing a self-report measure such as the Multidimensional Assessment of Interoceptive Awareness (MAIA), which has been adapted and validated across several countries and is used in experimental and clinical settings. In this study, the MAIA-2, which was developed due to the psychometric shortages of MAIA, was thoroughly translated, and its psychometric features were examined in a sample of 306 Norwegian-speaking participants (81% females, ages 16 through 66 plus).

METHODS

The participants completed the MAIA-2 Norwegian version (MAIA-2-N) and the COOP/WONCA Functional Assessment Charts measuring psychological, physical, and overall health. The following psychometric qualities of the MAIA-2 were investigated: factor structure, internal consistency, and the moderating role of gender.

RESULTS

Confirmatory Factor Analysis (CFA) revealed that an 8-factor model of MAIA-2-N provided the best fit. Also, a bifactor model revealed a proper fit. Good internal consistency and a moderating role of gender, age, and education on the relationships between certain MAIA-2-N factors and health were observed.

CONCLUSIONS

The MAIA-2-N is an adequate measure of IA in Norwegian-speaking individuals. The factor-structure corresponds with the original MAIA-2 and it shows good internal consistency. Some moderating effects of gender were observed, particularly related to the relationship between IA and physical and psychological state, with the physical state/fitness more closely linked to IA in males and psychological state in females.

Outcomes for binge eating disorder in a remote weight-inclusive treatment program: a case report

BACKGROUND

There are no known published reports on outcomes for medically and psychiatrically compromised patients with binge eating disorder (BED) treated remotely in higher level of care settings. This case report presents outcomes of an intentionally remote weight-inclusive partial hospitalization and intensive outpatient program based on Health at Every Size® and intuitive eating principles.

CASE PRESENTATION

The patient presented with an extensive trauma background and long history of disturbed eating and body image. She was diagnosed with BED along with several comorbidities, most notably major depressive disorder with suicidality and non-insulin dependent diabetes mellitus. She completed a total of 186 days in the comprehensive, multidisciplinary treatment program encompassing individual and group therapy, as well as other supportive services such as meal support and in vivo exposure sessions. Upon discharge, her BED was in remission, her major depressive disorder was in partial remission, and she no longer exhibited signs of suicidality. Overall, she showed decreases in eating disorder, depressive, and anxiety symptoms as well as increases in quality of life and intuitive eating throughout treatment, which were largely maintained after one year.

CONCLUSIONS

This case highlights the potential of remote treatment as an option for individuals with BED, especially in cases where access to higher levels of care might be limited. These findings exemplify how a weight-inclusive approach can be effectively applied when working with this population.

Body image, interoceptive awareness, depression and eating disorder symptoms: Within-group variability among sexual minority women

This study investigates within-group differences in body image concerns among sexual minority women and their related association with eating disorders and depression. Cross-sectional data were collected in 2017 and analysed in 2020 from 201 sexual minority women in the United States. Latent profile analyses and post hoc comparison analyses were conducted to investigate within-group variability in body image concerns and to understand their impact on depressive and eating disorder symptoms. Results suggested that a 5-class solution best fit the data, with five distinct profiles emerging in patterns of interoceptive awareness, sociocultural attitudes toward appearance, body shame, body surveillance and appearance anxiety. Significant differences in mean scores of depressive and eating disorder symptomatology emerged among the profiles; groups that reported low interoceptive awareness and high body image concerns experienced greater levels of eating disorder and depressive symptoms, compared to groups with average or higher levels of interoceptive awareness and average or lower body image concerns. Results underscore the significant within-group variability that exists for sexual minority women with regard to the prevalence of body image concerns, depressive symptoms and eating disorder symptoms. Efforts that aim to increase interoceptive awareness (for example, mindfulness) alongside strategies aimed at addressing negative body image concerns may be particularly effective avenues for future depression and eating disorder prevention in this diverse group. Our reporting adheres to the STROBE research reporting checklist.

Conformity to masculine norms, interoceptive dysfunction, and changes in muscle dysmorphia symptoms

Muscle dysmorphia (MD) is a psychiatric illness characterized by preoccupation and compulsive behaviors to increase muscle size/definition. Despite its severity, few risk factors/mechanisms for MD have been identified. Conformity to masculine norms may be a MD risk factor. Furthermore, interoceptive dysfunction may facilitate MD. symptoms, as well as underlie relationships between conformity to masculine norms and MD symptoms. However, research has yet to test the mediating role of interoceptive dysfunction for said relationships. The current study tested if interoceptive dysfunction underlies relationships between conformity to masculine norms and MD symptoms among 269 US men who completed three surveys separated by one month that contained measures of focal constructs. Our sample was majority White, heterosexual, and non-Hispanic. A three-wave autoregressive mediation model was tested in which conformity to masculine norms predicted interoceptive dysfunction, which then predicted MD symptoms. Results indicated that conformity to specific masculine norms predicted both interoceptive dysfunction and MD symptoms over time. Furthermore, our hypothesized mediation pathways were not discovered. Conformity to masculine norms appears to be a risk factor for MD symptoms and interoceptive dysfunction. If clinicians can reduce rigid adherence to masculine stereotypes, this may increase connection with one's body and reduce subsequent MD symptoms.

Embodying Consciousness through Interoception and a Balanced Time Perspective

This review presents current research and scientific knowledge in body mind sciences through the lens of interoception, as a representative of the body; and time perspective, as the representative of the mind. This intertwining dichotomy has been a subject of discourse in many fields, all having the common denominator of consciousness. Our aim is to expand on the congruities of these seemingly deconstructed worlds-of science and philosophy, of the body and the mind, to show that the place of consciousness lies in the zone between these two. Being aware of the body in the present moment. We introduce interoception and time perspective, focusing on how interoceptive signals are depicted in autonomic nervous system (ANS) regulation, and how this relates to the concept of a balanced time perspective (BTP), a highly adaptive psychological characteristic. Time perspective and interoception are also reviewed in the case of clinical conditions. We assess findings on interoceptive pathways in the body, finding convergence with balanced time perspective through the neuroanatomical lens. We conclude with findings that both dysregulated interoceptive states and a time perspective disbalance are recognized as defining features of mental disorders, proposing prospective practical therapeutic approaches, as well as implications for further research in the field.

From symptoms to subjective and bodily experiences: the contribution of the Psychodynamic Diagnostic Manual (PDM-2) to diagnosis and treatment monitoring in eating disorders

PURPOSE

Atheoretical and descriptive conceptualizations of eating disorders (EDs) have faced substantial criticism due to their limited ability to assess patients' subjective characteristics and experiences, as needed to determine the most appropriate treatment options. The present article provides an overview of the clinical and empirical literature supporting the potential contribution of the Psychodynamic Diagnostic Manual (PDM-2) to both diagnostic assessment and treatment monitoring.

METHODS

Following a discussion of the most relevant shortcomings of current diagnostic models of EDs and a description of the rationale and structure of the PDM-2, evidence supporting the core PDM-2 dimensions of ED patients' subjective experiences (i.e., affective states, cognitive processes, relational patterns, somatic/bodily experiences and states) are examined, alongside their relevance to ED diagnosis and treatment.

RESULTS

Overall, the reviewed studies support the diagnostic importance of these patterns of subjective experiences in EDs, highlighting their potential role as either predisposing or maintaining factors to target in psychotherapy. A growing body of multidisciplinary evidence also shows that bodily and somatic experiences are central to the diagnosis and clinical management of ED patients. Moreover, there is evidence that a PDM-based assessment may enable closer monitoring of patient progress during treatment, with regard to both subjective experiences and symptom patterns.

CONCLUSIONS

The study suggests that current diagnostic frameworks for EDs would benefit from the addition of a person-centered perspective that considers not only symptoms, but also patients' full range of functioning-including their deep and surface-level emotional, cognitive, interpersonal, and social patterns-to improve patient-tailored interventions.

LEVEL OF EVIDENCE

Level V, narrative review.

Temporal dynamics of interoceptive attention and positive and negative affect in adults engaging in disordered eating and nonsuicidal self-injury

OBJECTIVE

Interoception (the sense of the body's state) is associated with eating disorders and nonsuicidal self-injury, potentially through relationships with affect. We examined the relationship between interoceptive attention and both positive and negative affect.

METHODS

Participants (N = 128) who reported recent self-harm (i.e., disordered eating and/or non-suicidal self-injury) completed ecological momentary assessment for 16 days. Participants completed multiple daily assessments of affect and interoceptive attention. We then tested the temporal dynamic relationship between interoceptive attention and affect.

RESULTS

There was a relationship between positive affect and interoceptive attention such that people with higher average positive affect, and times when people were above their typical positive affect, were associated with higher interoceptive attention. There was a negative relationship between negative affect and interoceptive attention, such that people with higher average negative affect, and times when people were above their own typical negative affect, were associated with lower interoceptive attention.

CONCLUSIONS

Better mood may associate with greater willingness to attend to body sensations. Our findings support active inference models of interoception and highlight the importance of refining our understanding of the dynamic nature of interoception and its relationship with affect.

Adaptive depends on context: An examination of the Intuitive Eating Scale-2 in an eating disorder sample

Though there is a robust literature base linking intuitive eating (IE) to better psychological health and reduced eating pathology, little is known about the psychometric properties of IES-2 measurement or how IE relates to eating psychopathology within eating disorder clinical samples. Importantly, some seemingly adaptive eating behaviors in non-clinical populations could conceivably result from disordered eating within clinical eating disorder populations (e.g., not eating when not hungry because of distorted hunger-fullness cues, furthering restriction). This study examined the factor structure, psychometric properties, and correlates of the Intuitive Eating Scale-2 (IES-2) in a transdiagnostic eating disorder sample (N = 224). Participants at an eating disorder specialty treatment center completed the IES-2 upon assessment, along with other symptomology measures. A confirmatory factor analysis was performed, finding a poor model fit in this transdiagnostic sample, CFI = 0.889, TLI = 0.869, RMSEA = 0.095, TLI = 0.869, and SRMR = 0.099. Through exploratory factor analysis, we identified a factor solution for the measure that can be used transdiagnostically in this population, with revised scoring and modifications. As expected, the IES-2 demonstrated construct validity, with higher IE being associated with lower eating pathology (r = -0.36, p < .01), lower clinical impairment (r = -0.26, p < .01), lower body image dissatisfaction (r = -0.39, p < .05), and lower depressive symptoms (r = -0.20, p < .01), supporting construct validity. As anticipated, IES-2 was not related to emotion regulation, supporting discriminant validity. This study suggests that the IES-2 does not perform as expected in a transdiagnostic clinical eating disorder population, and instead, a revised scored 21-item IES-2 is suggested, with interpretation of only the total score and two subscales.

Longitudinal relationships between specific domains of interoception and muscle dysmorphia symptoms

Muscle dysmorphia (MD) is a subtype of body dysmorphic disorder (BDD); few risk factors for MD symptom development have been identified. One potential risk factor may be decreased interoceptive sensibility (impaired ability to recognize bodily sensations), which is present across a range of mental disorders. Notably, impaired interoceptive awareness is elevated in populations at-risk for MD. Furthermore, interoception is associated with MD symptoms, and theoretically, interoceptive dysfunction may facilitate engagement in MD symptoms. However, longitudinal research on interoception and MD is scarce, and specific MD symptoms implicated in these relationships are unknown. This study examined longitudinal relationships between specific domains of interoceptive sensibility and MD symptoms. Participants were 255 (26.7% Male; 72.1% Female; 1.2% Non-binary) undergraduates who completed two self-report surveys separated by four weeks. A path model was specified in which seven forms of interoception predicted five MD symptoms. Results suggested that interoceptive sensibility characterized by difficulties attending to bodily sensations and viewing these sensations as distracting predicted MD symptoms like muscle checking, positive attitudes towards using muscle-building substances, and compulsive exercise. Specific forms of impaired interoceptive sensibility may represent a risk factor for MD symptoms. If clinicians can increase the interoceptive abilities of their clients at risk for MD, this may prevent the development of MD symptoms.

The structure of eating disorder and somatic symptoms

Individuals with eating disorders (EDs) often present with somatic concerns in treatment, such as bloating, fullness, and feeling tight clothes on skin. However, most research generally focuses on general interoception (e.g., heartbeat) rather than sensations relevant to EDs (e.g., sensations related to the gastrointestinal system or body movement). In the current study (N = 181), we used network analysis to model the structure of ED symptoms and somatic concerns among individuals with anorexia nervosa, bulimia nervosa, and other specified feeding and eating disorder. Results showed that heightened sensitivity to somatic concerns had the highest strength centrality within a symptom network comprising ED and somatic symptoms. Exploratory graph analysis identified four symptom dimensions: cognitive-affective ED symptoms, behavioral ED symptoms, general interoception, and ED-specific proprioception. Findings suggest that heightened sensitivity to somatic concerns may maintain ED symptoms and mutually reinforce other somatic concerns. Implications concerning assessment and treatment of EDs are discussed.

Traumatic stress, body shame, and internalized weight stigma as mediators of change in disordered eating: a single-arm pilot study of the Body Trust® framework

To enhance access to evidence-based treatment it is increasingly important to evaluate scalable virtual programs that support the needs of those struggling with disordered eating. This study described a scientifically grounded, trauma-informed framework known as Body Trust,® and aimed to pilot test the preliminary effectiveness and mechanisms of change in a Body Trust® program to improve disordered eating. Using quality outcomes data, we examined 70 mostly white (87%) female-identifying (97%) individuals enrolled in a 6-module online program based in the Body Trust® framework (M_age = 45.5 ±10.9; M_BMI = 33.7 ±8.0). Putative mediators included traumatic stress, internalized weight stigma, and body shame. Outcomes were objective and subjective binge episodes, overvaluation of weight and shape, and eating concerns. Generalized estimating equations were applied to determine pre-to-post changes. We applied Montoya's MEMORE macro, the joint-significance test, and calculated 95% Monte Carlo confidence intervals to assess mediation. Significant pre-to-post improvements with medium to large effect sizes were detected for all outcomes and mediators (ps<.008). All hypothesized mechanisms supported mediation. Using the Body Trust® framework shows early promise for alleviating disordered eating symptoms through targeting traumatic stress, body shame, and internalized weight stigma. Given the program's use of mindfulness techniques, future research should test target mechanisms like interoception.

A preliminary exploration of experiences of integrating the body in the self in two women with anorexia nervosa in view of phenomenological conceptualisations

BACKGROUND

People with anorexia nervosa often present with confusions around bodily sensations and difficulties in experiencing their body as a place of their own. Many existing models understand anorexia nervosa as a disorder of behaviour and thoughts about eating and body size, and treatments typically focus on modifying thoughts and psychological processes. They leave aside the subject as she experiences the body from a first-person perspective. Inspired by phenomenology and the embodied mind thesis, this explorative study examines in depth the experiences of individuals with anorexia nervosa as they engage in Norwegian psychomotor physiotherapy. Through release of bodily tension and restricted breathing, this method aims to help subjects tune into the body and accept that difficult experiences, relationships and feelings are also bodily.

METHODS

Qualitative in-depth interviews were conducted with two women who had been attending Norwegian psychomotor physiotherapy for more than two years. Thematic analysis was used to identify, analyse and interpret themes within the data.

RESULTS

Three main overarching themes that structure the subjects' experiences were identified: the meaning of the therapeutic relationship, changes in bodily connectedness and ways of moving, and improved ability to articulate and reflect on feelings.

CONCLUSION

The subjects described a greater tendency to experience the body in the self and as a place of their own, a more flexible and vital body, and an increased capacity to identify, express and make sense of feelings. These changes enriched their interactions with the social world. Feeling acknowledged and accepted by the therapist throughout the process was essential. The study illustrates how difficult experiences, thoughts and feelings can, over time, manifest in the body as withheld breathing and diverse bodily constraints affecting both self- and body awareness. The study endorses the phenomenological concepts that our experiences of the self and the world are essentially bodily, and emphasizes the importance of the first-person perspective when investigating the contribution of the body to the self and to our interactions with the social world. Physio- and body awareness therapies that help patients relate to, understand and integrate bodily experiences may complement other treatment approaches and help patients with anorexia proceed with the recovery process. Having anorexia nervosa involve changes in the way one experiences the body. The condition has been linked to confusions around bodily sensations and reduced experience of the body as an integrated place of their own. The purpose of this study was to gain a richer understanding of bodily experiences in subjects with anorexia nervosa having attended a specialized physiotherapy approach. In depth interviews were conducted with two women who had anorexia nervosa and who had engaged in Norwegian Psychomotor Physiotherapy for more than two years. Three themes that structure the subjects' experiences were identified: the meaning of the therapeutic relationship, changes in bodily connectedness and ways of moving, and improved ability to articulate and reflect on feelings. The subjects described a greater tendency to experience the body in the self and as a place of their own, a more flexible and vital body, and an increased capacity to identify, express and make sense of feelings. Feeling acknowledged and accepted by the therapist throughout the process was essential. The study illustrates how difficult experiences, thoughts and feelings can manifest in the body as withheld breathing and diverse bodily constraints affecting both self- and body awareness in people with anorexia nervosa.

Time evaluation and its accuracy in eating disorders: differences in relation to interoceptive awareness

PURPOSE

Time evaluation has been poorly studied in eating disorder (ED) patients despite its relationship with body awareness, which is a core psychopathological feature in EDs and is influenced by impulsivity, interoception, and working memory. This study aims to evaluate time estimation and its accuracy across the ED spectrum in connection with specific and general psychopathology.

METHODS

A group of 215 women was enrolled in a computerized task involving the estimation of 1-min intervals. Impulsivity and body awareness constructs (self-monitoring, depersonalization, interoceptive deficit) were evaluated and examined for significant correlations with time estimation and the accuracy of the measure.

RESULTS

Patients with EDs showed an impaired ability to estimate time, with an accuracy that positively correlated with compulsive self-monitoring (p = 0.03). Differences between diagnostic subgroups showed an overestimation of time in anorexia nervosa patients and an underestimation of time in binge eating disorder patients, whose time estimation was also less accurate.

CONCLUSION

The relationship between time estimation and compulsive self- monitoring might corroborate the presence of an imbalanced integration of information in patients with EDs that was not present in the community women included in the study. Time perception should be further evaluated in the ED field, and longitudinal changes due to psychopathological recovery or BMI changes should be examined.

LEVEL OF EVIDENCE

Level III: Evidence obtained from a well-designed cohort or case-control analytic study.

"Feeling fat," disgust, guilt, and shame: Preliminary evaluation of a mediation model of binge-eating in adults with higher-weight bodies

"Feeling fat" is a subjective state that theoretically contributes to the maintenance of binge eating (BE). However, feeling fat, and its relation to BE among individuals with higher-weight bodies, has been infrequently studied. This study proposes a momentary-level model in which negative moral emotion states (disgust, guilt, shame) mediate the association between feeling fat and binge eating. In this study, 50 adults with higher-weight bodies (MBMI=40.3 ± 8.5 kg/m2; 84% female) completed a two-week ecological momentary assessment protocol, which measured experiences of feeling fat, emotion states, and binge-eating behavior. Univariate generalized linear mixed models (GLMM) evaluated the momentary associations among levels of feeling fat at Time 1, emotion states at Time 2, and binge eating at Time 2, controlling for Time 1 emotion states. GLMM results suggest that increases in each emotion from Time 1 to Time 2 mediated the association between Time 1 feeling fat and Time 2 binge eating. When modeled simultaneously within one multivariate multilevel structured equation model, disgust appeared to drive the relation between feeling fat and binge eating, over and above guilt and shame. Although preliminary, findings suggest increases in negative moral emotions, particularly disgust, mediate the feeling fat-binge eating association in adults with higher-weight bodies.

Nonmedical Social Determinants, Syndemic Conditions, and Suicidal Thoughts and Behaviors in a Treatment-seeking Community Sample: A Latent Class Analysis

OBJECTIVE

Knowledge gaps remain regarding whether syndemic conditions identify treatment-seeking individuals most at risk for suicidal thoughts and behaviors (STB). We employed latent class analysis to: (1) model treatment-seeking individuals' syndemic conditions, (2) examine latent classes across nonmedical social determinants, and (3) assess associations between class membership and STB.

METHOD

Participants were 982 individuals presenting at a community mental health clinic between October 2014 and February 2020. The three-step latent class analytic approach was used. Regression analyses were employed to examine nonmedical social determinants and STB outcomes associated with class membership.

RESULTS

Participants were aged 18 to >72 (75.8% White; 76.7% heterosexual; 53.7% cisgender woman; 73.8% earned ≥$20,000 annually). Latent class analysis resulted in a three-class solution. Participants in Class 1 were characterized by low probabilities across syndemic conditions. Class 2 was characterized by high probabilities of anxiety and depression. Class 3 was characterized by high probabilities of eating disorders, anxiety, and depression. Participants of color, sexual minority participants, cisgender women, and those experiencing financial distress were more likely to be in classes characterized by syndemic conditions. Classes characterized by syndemic conditions, relative to no syndemic conditions, were associated with greater risk of STB.

CONCLUSION

Findings confirm the concentrated clustering of co-occurring syndemic conditions among marginalized groups and highlight differing risks for those considering suicide or who have attempted suicide vs. those engaging in self-harm. Results underscore the need for resource allocation and multilevel interventions targeting syndemic conditions and suicidality for minority populations and those experiencing financial distress.

Boredom proneness, interoception, and emotional eating

Emotional eating is associated with weight gain and difficulty losing weight during weight loss interventions. Theoretical and empirical work suggest boredom may be an important predictor of problematic eating behaviors. Yet, little work has examined the role of boredom in emotional eating. Further, individual differences in the ability to recognize internal cues (i.e., interoception) may alter the impact of boredom on emotional eating. This study hypothesized that boredom proneness would predict unique variance in emotional eating after accounting for negative and positive affect, and that the association between boredom proneness and emotional eating would be stronger among those with poorer interoceptive ability compared to those with better interoceptive ability. Hypotheses were tested in two large samples using multiple linear regression. Participants aged 18-65 were recruited from MTurk (n = 365; 59.2% female) and an undergraduate research pool (n = 461; 52.9% female). Participants completed self-report measures: Boredom Proneness Scale; Dutch Eating Behavior Questionnaire- Emotional Eating; Multidimensional Assessment of Interoceptive Awareness-2; Intuitive Eating Scale-2- Reliance on Hunger and Satiety Cues; and Positive and Negative Affect Schedule. Boredom proneness was a significant predictor of emotional eating in both samples, even accounting for the broad dimensions of negative and positive affect (ps < .001). Interoception did not moderate the association between boredom proneness and emotional eating in either sample (ps > .05), but was an independent predictor of emotional eating (ps < .001). Boredom proneness and interoceptive ability may warrant attention as targets in the prevention and treatment of emotional eating. Future work should continue exploring different emotion categories and different facets of interoception in emotional eating, as well as examine novel mechanisms that could inform intervention efforts.

Methods used to assess insight in individuals with eating disorders: a scoping review

Insight can be impaired in individuals with an eating disorder and the nature of this impairment can vary. Although this topic has been the focus of several studies and reviews, methodologies used to assess insight have received less attention. A scoping review was conducted using a systematic search of articles before January 2021 to elucidate the methodologies used to assess insight in those with an eating disorder, with discussion of strengths and limitations. A total of 3089 studies were screened, and 24 quantitative studies which assessed at least one aspect of insight in individuals with an eating disorder were included in the review. Methods of assessing insight included coding of clinical notes, low scores on measures of self-report symptoms, direct assessment of insight, vignette, and self-report single-item questions. Insight into disordered eating symptoms was most frequently assessed. Most research used samples who were female, white, diagnosed with anorexia nervosa, and were seeking or receiving treatment. In designing future research and interventions, optimal methods used to assess insight should consider the research/clinical question, available resources, and the targeted demographic. Further, descriptions of which aspects of insight are being assessed should be considered in the interpretation of both current and future findings.

Revisiting alexithymia as an important construct in the treatment of anorexia nervosa: a proposal for future research

Consistent research supports altered emotional processing in adult patients with anorexia nervosa (AN), including elevations in alexithymia, or deficits in identifying and describing emotions and other internal experiences. Despite increasing interest in emotion-focused therapies for AN, alexithymia is often not directly addressed within many existing treatments, and little empirical work has moved beyond descriptive, cross-sectional research. In this paper, we propose that refining the field's understanding of alexithymia may provide insights into poor outcomes in existing psychological treatments for AN. First, we provide a brief overview of existing work exploring alexithymia in AN, and then describe several next steps in treatment-relevant research, including differentiating alexithymia from related constructs, considering neurobiological correlates of alexithymia, testing the link between alexithymia and outcome across treatment modalities, and piloting adjunctive treatment techniques focused on emotional identification and description. Altogether, exploring adjunctive treatment approaches targeting alexithymia may offer one promising possibility for improving long-term outcomes.

Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa

PURPOSE

Patients with eating disorders (ED) pose a high-risk group regarding relapse. The understanding of factors contributing to a better outcome is much-needed. Therapeutic alliance (TA) is one important, pantheoretical variable in the treatment process, which has shown to be connected with outcome. This review looks into a possible predictive effect of TA on outcome as well as related variables.

METHODS

A systematic review with pre-determined inclusion criteria following the PRISMA guidelines was conducted for studies published since 2014. Three previous reviews including studies up until 2014 were analyzed for studies matching our inclusion criteria. A total of 26 studies were included.

RESULTS

The results were heterogeneous between different patient groups. Regarding the predictive effect of TA, in adolescent samples, the TA of either the patients or their parents seems to impact outcome as well as completion. For adults, results are mixed, with a tendency to a greater impact of TA for anorexia nervosa (AN) patients, while some samples of adult bulimia nervosa (BN) patients did not find any relation between TA and outcome.

CONCLUSION

The effect of TA on clinical outcome depends on the patient group. TA has a greater impact on adolescents, irrespective of diagnosis, and on adults with AN. The examined studies have different limitations which include small sample sizes and questionable study design. The examination of motivation as a potential influencing factor is recommended.

LEVEL OF EVIDENCE

Level I, systematic review.